MAUDE Adverse Event Report: ATRIUM MEDICAL CORPORATION MESH PROLITE SELF-FORMING PLUGS; MESH, SURGICAL, POLYMERIC

Model Number 1010101-01

Device Problem Insufficient Information (3190)

Patient Problem Insufficient Information (4580)

Event Type  Injury  

Manufacturer Narrative

Investigation: based on the review of the device history records and product complaint details atrium can find no fault with the product.This lot of mesh passed all quality and performance requirement.Not returned.

Event Description

This event is deemed reportable based on the allegations in a potential lawsuit which, while unsubstantiated, suggest that a reportable event may have occurred during use of an atrium medical mesh product.Plaintiff allegedly experienced unspecified injuries and complications as a result of the implantation of the mesh implant.Since this is a potential legal matter, the case has been turned over to legal counsel and further information obtained through investigation or discovery may fall under the attorney/client and/or work product privilege.However, atrium will supplement this report as appropriate if additional information comes to its attention.

• Brand Name: MESH PROLITE SELF-FORMING PLUGS
• Type of Device: MESH, SURGICAL, POLYMERIC
• Manufacturer (Section D): ATRIUM MEDICAL CORPORATION; 40 continental blvd; merrimack NH
• Manufacturer (Section G): ATRIUM MEDICAL CORPORATION; 40 continental blvd; merrimack NH
• Manufacturer Contact: 40 continental blvd; merrimack, NH
• MDR Report Key: 11874248
• MDR Text Key: 252314382
• Report Number: 3011175548-2021-00569
• Device Sequence Number: 1
• Product Code: FTL
• UDI-Device Identifier: 00650862301014
• UDI-Public: 00650862301014
• Combination Product (y/n): N
• PMA/PMN Number: K002093
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: other
• Type of Report: Initial
• Report Date: 05/24/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 05/25/2021
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Expiration Date: 12/31/2018
• Device Model Number: 1010101-01
• Device Catalogue Number: 1010101-01
• Device Lot Number: 10924211
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 05/17/2021
• Was Device Evaluated by Manufacturer?: No
• Date Device Manufactured: 12/27/2013
• Is the Device Single Use?: Yes
• Type of Device Usage: N
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention
• Patient Age: 58 YR